Information Collection

FCC Form 497

IC 218852 under ICR 201711-3060-002 · OMB 3060-0819.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3060-0819 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
PRA enrollment application fields final 092217.docx	Other-Decription of Application Fiel
PRA for NLAD Reimbursement final 092217.docx	Other-Description of Lifeline ETC Re
PRA for universal one-per-household fields final 092217.docx	Other-Description of One-Per-Househo
PRA lifeline recertification form fields final 092217.docx	Other-Description of Recertification
FCC Form 497 Instructions_Final_7-11-16.docx	Instruction
FCC 5631 Lifeline Program Household Worksheet LI_ProposedFCC-WorksheetForm5631-10042017.pdf	Form
FCC 5629 Lifeline Program Application Form LI_ProposedFCC-ApplicationForm5629-10192017-OMB.pdf	Form
FCC 5630 Annual Recertification Form LI_ProposedFCC-RecertificationForm5630-10192017-OMB.pdf	Form
FCC 497 Description of Services Requested and Certification - Fi Lifeline Form 497 Field Descriptions Final-Cean 071216.docx	Form

IC Title:

FCC Form 497

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 47 CFR 54.400-54.423 47 CFR 54.201-54.207

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Decription of Application Fields			PRA enrollment application fields final 092217.docx	Yes	Yes	Fillable Fileable Signable
Other-Description of Lifeline ETC Reimbursement Data Fields			PRA for NLAD Reimbursement final 092217.docx	Yes	Yes	Fillable Fileable Signable
Other-Description of One-Per-Household Worksheet for Lifeline Program			PRA for universal one-per-household fields final 092217.docx	Yes	Yes	Fillable Fileable Signable
Other-Description of Recertification Form for Lifeline Program			PRA lifeline recertification form fields final 092217.docx	Yes	Yes	Fillable Fileable Signable
Form	FCC 5631	Lifeline Program Household Worksheet	LI_ProposedFCC-WorksheetForm5631-10042017.pdf	Yes	Yes	Fillable Fileable Signable
Form	FCC 5630	Annual Recertification Form	LI_ProposedFCC-RecertificationForm5630-10192017-OMB.pdf	Yes	Yes	Fillable Fileable Signable
Instruction			FCC Form 497 Instructions_Final_7-11-16.docx	Yes	Yes	Fillable Fileable Signable
Form	FCC 497	Description of Services Requested and Certification - Field Descriptions	Lifeline Form 497 Field Descriptions Final-Cean 071216.docx	Yes	Yes	Fillable Fileable Signable
Form	FCC 5629	Lifeline Program Application Form	LI_ProposedFCC-ApplicationForm5629-10192017-OMB.pdf	Yes	Yes	Fillable Fileable Signable

Line of Business: General Government

Subfunction: Central Fiscal Operations

Privacy Act System of Records

Title: FCC/WCB - 1, Lifeline Program

FR Citation: 82 FR 38686

Number of Respondents: 10,047,179

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	11,977,061	312,830	11,664,231
Annual IC Time Burden (Hours)	5,514,285	-559,790	6,074,075
Annual IC Cost Burden (Dollars)	468,750	0	468,750

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.